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To the Editor: In their letter, Spencer, Howe and Manolios call
for investment in fracture liaison services.1 Our own business plan showed that for an investment of $55 000 to hire a nurse, the dividend
is $1.5 million in second surgeries prevented. This plan has failed to impress successive chief executive officers or their finance managers,
and for good reason. The obstacle
is a financial paradox.

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